Basic Information
Provider Information | |||||||||
NPI: | 1578680989 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHILHAVEN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WELLSPAN PHILHAVEN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 785 5TH AVE STE 3 | ||||||||
Address2: |   | ||||||||
City: | CHAMBERSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 172014232 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172639555 | ||||||||
FaxNumber: | 7177096529 | ||||||||
Practice Location | |||||||||
Address1: | 283 S BUTLER RD | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | PA | ||||||||
PostalCode: | 170428939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7172738871 | ||||||||
FaxNumber: | 7172072401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2007 | ||||||||
LastUpdateDate: | 11/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HESS | ||||||||
AuthorizedOfficialFirstName: | PHILIP | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7172738871 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336I0012X | HP417104L | PA | N |   | Suppliers | Pharmacy | Institutional Pharmacy | 333600000X |   |   | Y |   | Suppliers | Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 1007720000002 | 05 | PA |   | MEDICAID |